Incident Type

Incident Description

Name of involved Person


Incident Date / Time

Was there a/or witness/s

Witness/s Name/s

Reported to

Position reported

Position reported to
Reported Date / Time
Asset Details
Equipment Involved

Asset Number / s

Shift Details

Roster Type

Days into Roster

Shift Start Time

Type of Shift

Shift Length


Detailed Description

Photo 1
Photo 2

Immediate Actions Taken


PE1 Was a personal safety check completed? If so attach a photo.

PE2 Were person / s experienced for the task?

PE3 Had they been adequately trained?

PE4 Did the person understand the task?

PE5 Was the person deemed competent to perform the task?

PE6 Were they physically capable of undertaking the task?

PE7 was stress adequately managed?

PE8 Was fatigue adequately managed?

PE9 Did the incident occur during the persons normal roster?

PE10 Was PPE worn?

PE11 Was the PPE worn correctly?

PE12 Was the person aware of the hazards associated with the task?

PE13 Did the person involved adhere to accepted procedures / processes?


EN1 Were weather conditions adequately managed?

EN2 Were any housekeeping issues adequately managed?

EN3 Was the location of the work area adequate for the task being undertaken?

EN4 Was the design of the work area adequate for the task being undertaken?

EN5 Was visibility adequate for the task being undertaken?

EN6 Was access/egress adequate?

EN7 Were toxic or hazardous materials adequately managed?

EN9 Were noise related issues managed?

EN10 Were roads / ground conditions up to standard?


EQ1 Was a pre-start inspection conducted?

EQ2 Was the equipment operating as designed?

EQ3 Was the equipment being used adequate for the task?

EQ4 Was the appropriate equipment / tools available for the task?

EQ5 Were all safety devices operational?

EQ6 Has maintenance been conducted as per schedule?


PR1 Were procedures available for the task?

PR2 Were they used?

PR3 Did they anticipate / identify hazards that led to the incident?

PR4 Are they adequate for use?

PR5 Was the person adequately trained?

PR6 Are required competencies documented?

PR7 Were area / location inspections conducted?


O1 Was there adequate and effective supervision available?

O2 Was training provided to personnel to conduct the task?

O3 Were any identified hazardous conditions corrected?

O4 Is there suitable availability of PPE?

O5 Are inspection / maintenance schedules adequately managed?

Corrective Actions
Action 1

Required Action

Assigned To

Due Date
Action 2

Required Action

Assigned To

Due Date
Action 3

Required Action

Assigned To

Due Date
Sign Off / Approval
Shift Supervisor


Safety Representative


HSE Advisor


Site Manager / Delegate


Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.